Hello Old Friend

Since you are a world renowned author and authoring another book, I thikn.  I ike to take this time and say it was nice to know you when you were just a lowly shrink. Best of Luck my old frined in all you do.

God Bless,
Joe

Physician Coders, Pearl Harbor Annniversary and other issue

Well I passed my Billing and Coding Exam for the AAPC, the American Association of Professional Coders. That is sort of the world that gets physicians and facilities sometimes paid. Every bill to a third party provider that is Medicare of a Private Insurance Company has to have a Diagnostic Code and a Procedural Code. There are thousands and thousands of codes, with several digits. For example the diagnostic code for PTSD is 309.81. In the billing and coding world if you don't bill the right and correct code and have the proper documentation it is a reason and an excuse for an insurance company to not pay the doctor or a facility, or at least delay payment. It is not like medicare or insurance companies have money sitting around and just can't wait to pay doctors. When you can delay payment or simply not pay a doctor and hope that no one notices, that money sits somewhere, typically it is gaining a bit of interest. So to delay payment or not pay is cost effective for the insurance company no matter whom it is. Most people that work in billing and coding do not understand this part. Moreover most people think doctors get paid lots of money anyway, way too much and this makes people angry, this attitude actually provides support to a system designed not to pay doctors if they don't have to.  Most people are oblivious too it.
Now there are tens of thousands of people that work in billing and coding. Keep in mind they have families they have to support and feed. The money to pay them comes from somewhere. It is considered a health care cost.
I took the certification exam because I wanted to understand this world. Most doctors coming out of residency and medical school don't even know a thing about billing or coding. We rely on others to do it for us. Of course without physicians there would be no billing or coding jobs. There are only a handful of physicians in the country that are certified coders. I suspect some or most of them are good business people. I know nothing about business.
Billing and Procedural Codes have nothing to do with the practice of Medicine, most coders don't believe that. The exam was 5.5 hours long. I had to go to the bathroom during the test, but could not allow myself the time, since the clock does not stop. To pass the test and become certified you need a 70%.  I was sure I flunked. Lots of people flunk. I got a 90%. I was happily surprised. I am turning fifty in one day and I worry that I am not as cognitively sharp as when I was 20 years old. However this test that lots of people flunk reassured me a bit- that I still got it.
The test is hard and chaotic like the world of billing and coding. You actually sort of have to think more like an attorney than a doctor. Find those hairline splits of the black and white dogma and make an interpretation. Remember lots of lawyers wanted to be doctors, but very few lawyers "settled" for medical school. Medical School is harder. The coding certification test was really hard. Maybe as hard as a test in medical school.
I take care of patients all day, every day. regardless of how I feel or how I am doing. I get to give 110% every day to patient care. Call it a responsibility, a burden or a privilege, it is what it is and I probably won't quit my day job anytime soon to be a coder. If many people and entities have their way, we can maybe drive most doctors out of the practice of medicine and make it so arduous to practice medicine that no one wants to go to medical school. Then nurses, technicians and computers can practice medicine, the masses of people will be so dumbed-down by society, that they maybe won't know the difference. Some think this will save money. It won't. I dont' know if this will happen in my lifetime, but I am happy to be a bit more versatile with a certification in coding, should physicians practicing medicine become obsolete. I may have a marketable skill.+++

Now take a moment to remember in your hearts and in your prayers those Veterans of Pearl Harbor and WWII. It happened seventy years ago today. The last great generation, the last War the United States flat out won. I've visited  Pearl Harbor and I've been to Hiroshima. Both are incredibly moving places. There are not so many WWII veterans living anymore, they would be in their 90's, many of them. Thank God for them, because there is a good chance that I would not be writing this blog and you would not be reading it, if it was not for them. 

PTSD, and Alzheimer's Treatments- FDA-on-label or off label, formularies, studies

So what is new with the treatment of Post Traumatic Stress Disorder? Well we still have two government approved meds, one is Paxil (paroxitine) and one is Zoloft (sertraline). It has been over ten years since these were approved and have been indicated by the FDA for the treatment of PTSD. Sometimes they help and sometimes they make things worse. Basically most psychiatric meds out there have been used for somebody somewhere to treat PTSD.
A few basic facts:
Most people associate PTSD with veterans of combat wars. The truth of the matter is in shear numbers there are more civilians with PTSD than veterans. However for those military veterans whom have served in combat there is a much higher percentage of that sub population with PTSD than in the general population. Combat increases the possibility of developing PTSD. Not everyone whom has serves in combat gets PTSD.  The reason there are a larger number of civilians with PTSD is that there are simply more civilians  than those whom have served in the Military, by shear numbers.

The percentage of women with PTSD is higher than men 10% versus 5%. Most traumas being physical and sexual abuse and violence and the same for men as well as combat. Motor vehicle and work accidents are also not unusual sources for the trauma.

Most people that have experienced a psychological trauma (an event involving death or serious injury witnessed and involving certain responses like helplessness and terror) do not develop chronic long term PTSD. However about 30% of people do develop it. (Millions of people).

As far as treatments, remember the FDA does not do drug testing, they simply review what comes across their transom, IE mostly studies submitted by the industry (pharmaceutical). PTSD like Alzheimer's disease, is really hard to treat and no one med emerges as the gold standard. Therefore drug companies don't want to touch it. It is more lucrative to simply refine and develop another  med in say an illness that does already respond well to medications, like good old major depression.
It is hard to get a med that sort of works for some people, some of the time and spend billions on it only to have the FDA say "no-go drug company, it does not work well enough consistently". . The drug companies like to stick with things that they know will work, and the studies will show really good results so that the government will approve it. The  FDA does not say "Hey get more meds for PTSD and Alzheimer's", that is not in their cubicle or jurisdiction to do so, even though we all know we need to develop more and better meds to treat these two catastrophic illnesses.

We have lots of meds used "off-label". Example a patient with PTSD has tried paxil and zoloft and they get worse of they get side effects and can't tolerate the med, you can't really send that patient away for years, till we have a new FDA approved med we can offer. In other words there are lots of studies and data indicating efficacy and positive results on a certain med for say PTSD.
 Researchers like to get published, they like to refute each other, They like to get a name and get famous. Sometimes the drug company funds a study and shows great results and then others say it does not count because the drug company did the study and therefore the way the study was set up was not good science-- since the study  was designed to show the med worked.

Sometimes studies are set up with the hopes of showing a med does not work:

Why would that be? Well if a med is really expensive and a doctor knows it works for certain patients but say he or she works within a health system that has its own pharmacy formulary that only covers certain meds, then it may be too expensive to tpay for that med. So it is not listed  on the formulary. Therefore that doctor won't be able to get that med within that health system for that patient.
Now if you can get a big name, big time, researcher to set up a scientific study to show maybe that type of med is not effective, even though the doctor may have been using that med or combination of meds for years to help patients. Now the doctor can't get it because he wont' be going with the most recent studies and evidence.
It would make the doc look bad if he went against that most recent, vogue, trendy scientific study.
End result is doctor is not allowed to prescribe the med they know is best for their patient.
Remember formularies are negotiated between health care systems and insurance companies and have nothing to do with if a medicine being helpful or not. It is basically economical and not clinical. But if you can get a good study from a big name researcher behind it -to dispute a meds clinical efficacy, it just happens to be 'cooincidently' economically desirable and sweet for the health care system. The slug doctor and the poor patient are caught in their middle and not heard.
Remember also if a doctor is prescribing something "off label" that is for something not indicated by the government, even if they are trying to help their patient and there is a bad outcome, in some jurisdicitons, that doctor is liable and a bad doctor.Yet if the doctor knows there is an 'off-label" treatment that works well in may patients and they withhold it from the patient because the drug company did not push it through the government to get an indication, then it may be unethical for the doctor to withhold that "off-label" treatment if they know it has the potential to provide benefit.

Conversely when a med comes out on the market, that has gotten approval from the FDA for some indication or another, and even been advertised on TV,  the doctor may know in certain patients  or most patients that it does not work as well as the studies and the TV commericals show based on real life clinical experience then what does the doctor do? Direct to consumer advertising makes patient ask for meds by name. It builds instant credibility. If the governement approved it, and the doctor does not pracitce exactly what the govenremnt says, and what the TV commercials say, should you get a new doctor?

Does the Pain of Alzheimer's Ever go Away?

It has been over thirty years since my mother was diagnosed with Alzheimer's. It has been 24 years since she died of the disease. I was seventeen when she was diagnosed, my book talks all about that struggle. But something is happening now around me now and it is very strange and very sad. It stirs a myriad of emotions for me. I was a junior in high school when my mother was diagnosed. There was no Internet, no Alzheimer's Association, no blogs, no Aricept, generally no awareness and no hoopla. We had "hardening of the arteries" and old people were "senile". That was about it. For awhile I had to sort of cover up to my friends, my mother acted weird, sort of crazy. It was most embarrassing and humiliating. It made me really enraged. Now some thirty years later I am getting phone calls from many old friend whom are now going through what I went through when I was 17. All the signs and symptoms of dementia. Nursing homes, sibling power plays. Meds, Aricept, Excelon, somehow now I am the expert having lived through all this so many years ago.
They turn to me for advice. Sadly I don't have the answers in the end. I can tell them all about the meds, all about my experience, but in the end for most of the dilemmas, there is no right answer. Should my mother go into a nursing home? She she keep living at home? Is it safe. What is the difference between dementia and Alzheimer's? For some questions I have very clear and informed answers.
With other dilemmas like the nursing home question I advise there is no correct or perfect answer, you have to try to do the best you can, of course you want to stay in the home as long as you can, but when is it not safe, who decides? Basically you do the best you can and no matter what it is going to hurt and it is going to hurt am lot.  
Two old friend from high school and college had parents die this year, once again in a perverse way I am the expert. Having gone through it when I was a kid, all I can do is listen. It was impossible for many friends to conceive how bad it felt for my father to die in high school or my mother to get Alzheimer's disease.
I wish people could have related to me then, they couldn't.
Now so many years later,, I am hit with a wave of sadness and anguish for them, I know it hurts for them at  50 years old as much as it did for me at 17 years old. I am filled with sorrow and a deep compassion for them, I want to fix it but I can't.  I listen and tell them that is how I was feeling back in high school, so long ago, it is a strange and surreal experience.
Do I feel indignant because none of these friends could really understand me back then like I understand them now? Not really, just a real deep sadness for them. They will go on, but it is never the same, loosing a parent to AD is as bad at 15 as it is at 50 or 70, it is always bad.
Then we can talk about the resilience of the human spirit. Makes us feel better. I like to refer to it as a survival instinct and that's about it. I am convinced that had my father not died when I was sixteen or my mother gotten Alzheimer's disease, I would have been a hell of a lot stronger as an adult and would have had a much easier time of it. And no I am not talking about getting through medical school and all the hateful stereotypical prejudices people have against doctors, I am talking about life. So call it resilience or survival instinct,. Nietzsche was wrong when he said "what does not kill  me makes me stronger", that is total BS. It greats on you and tears at your psychological and spiritual core, we are human beings not robots.
Alzheimer's is isolating and it always hurts, regardless of how long you have lived or how strong you think you are. I tell My Friends I know how they fell, I am so sorry, and I know they will get through it. I relate to their every scenario, every painful situation, and regardless of all the hoopla around Alzheimer's in 2011, the pain of what it is like for my old friends to now live with an Alzheimer's parent has not changed at all in thirty years, it is the same stuff, the same pain, I went through as a kid. It hurts them now as it hurt me then.I am sorry I had to go through it and I am so sorry people still have to go through  it., but you will make it..

Would you recognize the early signs of Alzheimer's? - Healthy Living on Shine

Would you recognize the early signs of Alzheimer's? - Healthy Living on Shine:

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am only posting this so you read the comments. I want you to see what folks really think about us. remember you heard alot of this from me, i think.

God Bless,

joe

Duluth, Minnesota Alzheimer's Walk

Its that time of year again. Annual Alzheimer's Walks to raise money to benefit the Alzheimer's Association, and happening all over the country. Here are a few pictures from the one in Duluth, Minnesota at Spirit Mountain. As you can see it was a beautiful fall day, last Saturday Morning. Lots of people, including myself turned out. Congratulations to the Local Alzheimer's Association in Northern Minnesota Region for a successful and well attended event.

Really: What is New In Alzheimer's Research?? Diagnosing AD

Well here we are in late 2011. One of the things that is astounding to me is the disconnect between the research  experts and those in the daily grind. If you are the caretaker of a loved one or live with someone with AD you are the real expert in my opinion.
So we have no cure, we have  no definitive way to treat  it and we have no definitive way to diagnose it with 100% certainty except brain biopsy or autopsy of brain. I need to re notify and present those grave and awful facts to give an understanding and perspective of where things are at and break it down for the general public, so we can understand exactly where the current efforts to combat the disease are at. I suppose a lot of websites and organizations try to do that, but it is not always easy to follow what the heck is going on with AD.
The hottest research,  at least what is put out to the media outlets, and available to you and me is in diagnosis. In terms of treatment or cure, one of the things you have to understand is that a lot of the medicines and treatments and funding for studies comes from the private sector IE. big old pharmaceutical companies. I think you know as well as I do that drug companies are considered sinister, evil and only concerned about the bottom line. Everyone likes there funding though. But with the Obamacare crisis- the acceptance and positive regard  for drug companies is probably at an all time low. That actually hurts research efforts for things like Alzheimer's disease. -(swear to God)
In Duluth, MN- a city and state that arguably, collectively loves to hate physicians as much as any place: I can barely even talk to drug reps anymore. I almost don't let them in my office. If a doctor around these parts does interact with a drug company representative, then his or her name may be smeared all over the local fish wrapper newspaper for being bad as a doctor and moreover as a human being and everyone believes it.
Who is going to pay for the research. Just dont' hear much about the plight of AD with the health care antics, do you?
So take it up with the publicly funded agencies like the NIMH and the NIH. Very politically correct since they are "PUBLIC". Publicly funded research is up there with the perceived unconditional altruism of the "non-profit" tax status entity. Whatever way you look at it, they are all politically correct right?
I am not going to even get into the funding for AD research relative to many other diseases, but lets just say by looking at the numbers, we can draw an easy conclusion that AD research may be underfunded in the public sector.
So the thought leaders: those in the Research trenches while  liasoning up with the Alzheimer's Association, want to figure out a better way to diagnose AD other than a brain autopsy. We want to diagnose it early. Really really EARLY. Early diagnosis without question is good-clinically and  humanely it is ALWAYS good. I will not consider the economic, bio-ethical and therefore political implications- the liberal weasels will talk care of that, and it won't be pretty for  those whom care about the sanctity of human life- like myself and perhaps most readers of this blog.
Now let's think about the AD process. It is a two-fold process: internal and external.
There is something internally going on at the brain cellular level and also something externally going on with the victim- the behavior, the memory, the personality changes-you caregivers are the experts on the external manifestations of the disease. You live it everyday.
Now consider this-A person does not wake up one day and have Alzheimer's. We all know this  and it is established that there are changes at the brain cellular level and gross physical biological changes to the brain. Amyloid and such- the battle cries and buzzwords we have all heard before. plaques and tangles amyloid and tau
It should not be a leap of faith to say that the internal changes to the brain start before the external changes. That's just how the brain and the disease works. Remember we have millions and millions of  brain cells, and if you kill one cell nobody is going to notice too much. The disease has to destroy a lot of brain cells to notice externally, that can take years.
Researchers want to make the diagnosis early in the process, really early. Once again, what is happening internally to the brain and the cellular level in an AD victim may start years and years MAYBE even decades before the external change start when victim starts showing the signs of Alzheimer's all of you are so familiar with. If you get it early there might be something more we can do about it. Maybe some day at least stop it before it advances.This is a good thing. It is why we want to find it early, before the external manifestations start.
Now how do you do that. Basically we can look at pictures of the brain, through neuroimaging, CT MRI, PET SPECT all kinds of elaborate scans. We can tag certain cells to go to certain parts of the brain that might be showing changes in Amyloid composition per say. not new to medicine but in terms of radioactively tagging cells to look at the brain, it is not as common and established as say a scan of the heart using tagged cells.
So there is a big area-Advancing Neuroimaging, sophisticated picture of the live human brain and its real time functioning. in PET scans, one of the really expensive but promising radio tracers is called (PiB)  which is short for:
Pittsburgh Compound B This can help trace and assess Neocortical amyloid Burden or how much amyloid is accumulating in the brain, with pretty good accuracy.
The second diagnostic tool we have is laboratory tests either blood or cerebrospinal fluid. Biomakers Biomakers and Biomarkers. BIOMARKERS.
So that's it. We have blood (and spinal fluid) and neuroimaigng to work with, and that's about it. Not too much else these days. Those are the main things we have to work with in terms of diagnosing that disease when it is still internal and otherwise invisible, years before it externally manifests itself. Yes of course we have genes to look at and work with, but we have been barking up that tree for a few decades now, and it really isn't totally panning out for everybody across the board as a gold standard to definitively make the diagnosis or rule it out in anyone and everyone. So take some of those better studied genetic markers like ApoE, (well discussed everywhere now)  and lets clump them into blood work studies.
Now is there a way we can combine all the bloodwork and biomarkers and Amyloid Burden in the Brain by imaging? Is there???
Well it just so happens that the AIBL (Australian Imaging, Biomarkers and Lifestyle Study) is working on doing just that.
Basically they took 273 people , performed the expensive PiB-PET scans and then also took bloodwork from them. Studying the blood they used 9 different biomarkers in a panel, thing like cortisol and ApoE were tested in the blood panel. They figured out the biomarkers that would correlate with the different amounts of amyloid burden in the brain that would predict and be consistent with developing AD.   Basically not an easy thing to do.
Then they took another 817 people or so and didn't do a scan. They clumped these people into clinical diagnosis: AD (external Alzheimer's); MCI (mild cognitive impairment); healthy individuals.
!00% of the Alzheimer's victims had a  high neocortical burden based on the blood panel with the 9 biomarkers, (remember the panel correlated with the neuroimaging originally that showed the brain amyloid.
Okay so what does it all mean?
Basically it is moving us a little closed to developing a blood test to allow us to diagnose AD much earlier before it externally manifests. No we are not there yet.
The idea is neuroimaigng is too expensive, getting a spinal tap is too invasive , and we need a good blood test that will work for everyone to make the diagnosis before the disease outwardly manifests.
Remember all the research is happening around the world not only America. As I said in previous posts, it is collaborative and competitive. Everyone wants to be the first to make that discovery. No one openly admits it. That just would not be altruistic. '
So that's where the efforts are. If we can get it diagnosed early, have a mainstream blood test that you can get at the primary care clinic, then perhaps we can find more effective treatments earlier on inn the disease process. . If we don't have meaningful  treatments, but we can diagnosis it  really years earlier... well the way American society it acting,  We will be in really big trouble.

PHYSICIAN BURNOUT!

Wow, what is it? Last I checked physicians were not allowed to "burnout".  Burnout is even somewhat poorly defined, since it is not a clinical concept. Everybody knows what it is but it looks different in different people. Consider it a chronic state of emotional, physician, intellectual and spiritual exhaustion-In this case induced by ones job, or occupation or in this sense I still use the term profession. It can manifest with more cynicism, physical health problems, addictions, calling into work sick-(doctors don't get to), anger, irritability, slowed cognition, anxiety, marital and relationship problems and of course the catch all term "depression". Sometimes the depression is a clinical depression.
People end up hating their work, retiring early (if they can) switching careers( if they can) and a whole host of other consequences.
The fact of the matter is just a few years ago, almost all physicians wanted their son(s) or daughter(s) to become doctors. Now only some 30% encourage their children to go into medicine. Most docs over fifty years of age want out ASAP.
There are lots of little initiatives to help physician burnout, often run by para-professionals, psychologists, nurses, you know people that didn't go to medical school, didn't give up all of their adolescence and most of their adult lives to serve. Interestingly enough many of the physicians who lecture about physician burnout have gotten out of the game, they have gotten out of direct patient care.
Now I will tell you the rest of the story, that no one seems to comprehend, even most physicians, the anti-physician New York Times media type outlets, and the general anti-physician mainstream society.
Most.....no make that ALL doctors who make it (WHO MAKE IT) IE gotten through school, residency etc. want to serve others, they want to help patients. They are also as a whole very self-punitive, very even shame based, we are our own harshest critics. Most take it very very hard and suffer in silence when things do not go well with a patient. Moreover we are not allowed to whiners, it is politically incorrect, and just plain wrong if you are a physician, this blog is just plain wrong- because it talks about the things the smiley faces whom have gotten out of the clinical world and make a decent living, as well as all the physician despisers annoyed-  it is uncomfortable to think about.
Most docs are perfectionist by nature, everyone whom isn't this is WEEDED OUT in the 12 year process. The integrity and commitment is phenomenal, and yet their is something profoundly masochistic and self-punitive about the culture and very nature of the indoctrination of becoming a physician. In other words you pretty much give up yourself, it is selfless. That is in the backbone of any good physicians, and most are good. The not so good one 'wannabes', did not have the intellectual or spiritual or emotional commitment.

So here is a secret, maybe not a secret but a taboo statement within society.- a lot of physicians want out of direct patient care, this is where the stress and burnout comes from. Why? There is more pressure than ever, to see patients- as many as possible, that pressure comes from payers, administrators etc.
There is literally a bulls eye on physicians backs in regard to litigation, when we don't get the outcome we want we immediately want to sue the doctor. We want retribution, accountability. We want our doctor to be perfect, to know everything and have a wonderful bedside manner.
But nowadays we live in such a physician-hostile climate, we are ready to sue if something does not go our way. It is another pressure. Also we really place no actual value on the doctor. We know how much it costs to get our oil changed in our car or to get a crown on our tooth at the dentist, but we never really know how much a doctor's appointment costs. Moreover we get huge uncovered bills from institutions and the general assumption is that all that money is going into the doctors pocket. I will never be able to convince anyone outside of medicine that the doctor does not see that money. It helps us devalue and hate the physician even more.
And here is another concept- there is generally a breakdown of the family more social media, less human contact and intimacy and perhaps as a society we treat each other with less respect than ever. Call it a post-war pervasive narcissism except know we are about 5 generations post war, and have been busy indulging ourselves for decades, feeling good putting ourselves first, convincing ourselves that the destruction of the nuclear family is cool and politically correct. what does this have to do with physician burnout???
NO ONE WANTS TO PAY TO BE CARED ABOUT. The physicians office is one of the few institutional bastions left in our ever-advancing society where a person is supposed to and can feel cared about.
With that said a person can never feel cared about from the nurture they didn't get from their fragmented family of origin.   Now couple that with a doctor whom you don't pay- (insurance does or does it?) and that doctor is working hard to be good enough and help you as much as they can, but it will never quite be enough given the combination of factors conscious and unconscious between patient and doctor. It is a perfect storm for an -anti-physician society to advance their distaste towards doctors and an even more perfect storm for physicians whom actually take care of patients all day, to become really really burned out.
But since we are so shame-based, it is completely taboo to say we dont' like treating patients anymore. That is a sign of being bad, and that is the LAST thing a doc wants. So we burnout or quietly switch careers, except most docs have no marketable skills outside of medicine.
Physician burnout is more complex than eating right, balancing work and play, getting enough sleep, prioritizing family, exercising. Yes all that stuff is crucial to avoid burnout but it really needs to be understood, from a developmental and personality-character perspective to be able to do something more about it. One must also consider what has happened to society in the last four generations, to understand why there is more physician burnout.
I would love to see a doctor that still takes care of tons of patients all day speaking on burnout, except they don't have the luxury. Sorry I'm just whining, I must stop. I know like all good docs all over this great nation of ours, I will just keep trying harder every time.

WAM Match Appeal #1: Advocates 9-2-11

WAM Match Appeal #1: Advocates 9-2-11:

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caring for those with Dementia.

God Bless,

joe

Eternal Peace or endorphin release, or God, religion, afterlife, the divine

Well it has been a really long time since I blogged.  The summer is officially gone by us as we just finished labor day.  It is coming up on two years sincee I fell off a scooter and broke my face in 4-5 places. I have ringing in my ear and a tumor called an acoustic neuroma, which Mayo clinic can do nothing about except watch it and charge me lots of money that my insurance won't totally cover to pay for staging it once a year. It is on my cochlea which is sort of the end of the eight cranial nerve the other end connects up to your brain.
Also loosing my hearing in that ear. Because of location that won't operate. More later on this.
Not too much new on the AD front. Australian study and Mayo looking at a bunch of blood markers, a whole panel of tests to try and identify Alzheimer's in people before it becomes clinically apparent and obvious.  So earlier recognition is where it is at. Testing and findingg it before it becomes apparent, maybe years before. No clear treatments emerging. 
So this summer I went to a Benedictine Monastery for a few days in St. Leo Florida mostly to pray for healing for my ear. I ended up praying for my enemies and people I can't stand. My ear did not get cured but me stress level went down considerably.
I also ran my first 5k marathon this summer, ironically with the exception of the cancer in my ear, I am in probably the best shape of my life at nearly 50 years old.
I had a bit of a spiritual moment.  I was with my son and a climbing friend. We climbed the South Sister in the Cascades in Central Oregon. The summit is about 10,500 feet or so. We started at 5AM and completed the summit about 12 noon. Note that this is a climb I never completed in 1994 when I was 33 years old. I started out to late in the day on that one. Now at almost 50 I completed the climb.
On the way down we rested a few times. At one point, I sat down then layed back. The sun shined on my face and warmed me on the side of the mountain.  I said aloud, "this is what it must feel like to be dead." I didn't mean it in a bad way, but it upset the friend my son and I were climbing with. He said, "don't talk like that." What I meant what I felt so incredibly at peace, I wished for nothing, felt no stress or worry, just the beautiful sunshine warming me. It was so incredibly comfortable. I corrected my self and said, "No I mean this is what heaven must be like." I felt really peaceful and loved and even connected to God. Nothing hurt, I can't remember my ear ringing or throbbing, just peace.
This happened a couplee weeks before I went to the monastery.
It is unusual to have an experience like this. One could say I was exhausted from climbing for 8 hours and it was cold and brutal winds at the top of the mountain but on the way down it was sunny and nice. Perhaps it was endogenous opioid release,  a similar feeling a person may get from taking opiates.
On the other hand it simply could have been God and a peaceful loving content and fulfilled feeling.
You see how I struggle between the science and the spiritual. 
At any rate I was lucky to have this moment, this time where I felt close to God.

SOUTH SISTER in OREGON

After loosing my parents at an early age, a lot of life has been filled with a certain stress, sometimes an anguish, (read the book) like everyone I have my struggles. As a doctor and a psychiatrist, a lot of my life is surrounded by the worst pain and evilness known to mankind and the terrible things that human do to one another and how it affects them. So if I get a moment on the side of a volcano and it is complete with human fulfillment I have to take it as a sign from God. I wish I had more of those signs, but we take what we are given. It was a good thing, perhaps a divine thing.

Thanks to Normal, Illinois for Book Signing

Lots of thanks to the very kind people of Normal, Illinois for coming out to the book signing at the Library last week. Here are a couple of pics from that signing.

New Blog: Medical Fiction Writer and other updates

Good Day. Long time no blog. I have been busy with some Health Care Issues lately. In fact I have been down to Mayo Clinic twice since I last blogged. (Great Venipuncturists at Mayo, also fairly decent restaurants in Rochester, MN) I won't bore you with the details right now, needless to say it sucks, but then you go on as best you can,  as time keeps marching on.

Also I have been busy trying to survive as a Private Practice Physician in the State of Minnesota, despite the best efforts of  many bureaucracies and agencies to annihilate entities like myself: all done of course shouting the Battle Cry and in the name of health care "REFORM".  When it is all said and done, we will still need doctors to take care of patients and patients who need to be cared for and cared about by their doctors.
It is absolutely astounding how many people are now employed (with really good employee health benefits I might add) to hinder, hamper, occlude and basically prevent physicians from simply spending their time taking care of their patients. ASTOUNDING

On the lighter and more fun side of things, I started a new blog.
It is called MEDICAL FICTION WRITER CHECK IT OUT. Not too much there yet, but it will get there. Over the last couple if years I wrote another book. very different than When Can I Go Home?. This one is a work of - you guessed it-medical fiction.  It is sort of a drama, action, crime, romance, with chaos, violence, doctors, lawyers, courtrooms, lots of things. Stay tuned. I'm in the process, a very grueling process of doing the first edit.
The blog will be for writers and readers and about writers and readers of medical fiction. and of course Medical Fiction Books.

For all you Alzheimer's caregivers, it is Summer at least in the Northern Hemisphere, if that's where you are. Try to get outside for some warmth, even for a little while. Keep the faith, do your best, I know you didn't sign on for this, but I am sending you my positive thoughts, hopes and wishes and energy right now. What I still have of that positive energy, it is there just below the surface of my cynicism! I promise though, that positive energy and hope is real in me, just as it is in you, whether you know it or not.  So don't get too lost in losing the daily battles, overall by caring for your loved one, with your devotion and dedication, you are winning the war on this thing.
God Bless.
 

Brand NEW BOOK SIGNING and Alzheimer's Q & A suburban Chicago and the Heartland

Monday June 20, 2011 - 7 PM Evanston Public Library, Evanston, Illinois

Thursday June 23, 2011- 5:30 PM Normal Public Library, Normal, Illinois

CLICK HERE FOR MORE INFORMATION

Happy Mother's Day

Happy Mothers day, and for all of those with dead mothers, those who have lived though so many of these mother's days without the support, the basic self-esteem and innate confidence that come from having a mother on this earth, you are not alone. God Bless and carry her strength and love with you.

Oh and if you are fortunate enough to have a Mother on this Earth, don't forget to honor her the rest of the year, not just Mother's Day with brunch and flowers,

Nocebo Effect-Blog Post From FreeLance MD

Here is a post I did for Freelance md  it is on the Nocebo effect. Another Website Called Physician Nexus added it to their site. I was invited to post and told I could post on anything I wanted, related to medicine or doctorhood. Well that covers about a billion potential topics. I wanted to cover something out of the mainstream, that you won't see many people write or talk about, for a whole host of reasons. If you have any questions, please feel free to ask or comment.

NEW PODCAST- Delirium vs Dementia vs Delusion Some Considerations

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Here is a new podcast on Delirium, Dementia and Delusion. Some of the major differences and considerations. If you have quesitons please email me or comment below. The podcast is in lecture format, and there is too much to cover for one podcast, but some major features and genreal informaiton are discussed. These issues seem to come up frequently on the blog in search engine queries, so I hope this podcast is helpful.

Book Giveaway Winner Goodreads,and New Zealand stuff- love the Kiwis

Congratulations to Stan down there, over in Christchurch, New Zealand. He is the winner of the When Can I Go Home? Goodreads book giveaway. He will receive a signed copy of the book.
I have got to say I love and always will have a fondness in my heart for New Zealand. Long ago when I was a young man like age 32, in the early 90's, I worked a locum tenans psychiatry job in old Palmerston North, New Zealand. working at Wanganui-Manawatu Health later named Mid-Central Health. I was fresh out of residency and life was hopeful. It seemed optimistic that you could actually pay off your loans and get out of debt as a practicing psychiatrist. -Ha!. It seemed like being a physician was a respectable thing to do in society (I hadn't lived in MN yet hah ha.) and all around life was okay. The world seemed my oyster. So I explored the world including N Zed.
Working and paying taxes there was interesting. The things that I remember most about the work are the fact that the Kiwis never seemed to wear shoes in the summer. I was there in Dec and Jan, the middle of summer. In terms of psychiatry the thing that I will never forget is that NZ was a much less violent society. It came out all the time in the daily practice of psychiatry. The Kiwi's were not always interested in getting ahead of one another, of messing one another up of dominating one another, of killing one another. It affected a person's mental health. It was a cultural phenomenon. They were less violent. It was also nice not to take you life into you hands every day as many American psychiatrists have to. They were polite too. "Please" and "thank-you" were rampant.
I remember the boiling ground and Geo-thermic activity in Rotorua, Jet Boating, Climing Mt Taranaki or Eggmont, whichever you prefer; Repelling into a cave at Waitomo and wathcing glowworms on the ceiling; hitch hiking from Nelson on Christmas Day to get to Picton, to catch the Ferry across the Cook Straight to get back to work,  and of course bungi jumping at Lake Taupo (I enclosed an old pic)
Driving on the left, eating pies for lunch, meat pies (before I had to worry about cholesterol)
Hanging out and exploring and doing many of these adventure with my buddy Darren, who worked as a psych tech.

Sad to say I only spent a few hours in the city of Christchurch on the South Island, where Stan lives. Remember that's where the earthquake was, It seems in the United States if something is not blasted in our face by the media we quickly forget. It was only a couple months and 181 people died there. So remember them and their families in you hearts and prayers. Now is the hard part for grieving. Remember all the "disaster mental health experts" have pulled out, because there is now little chance of getting their mug on the TV and flaunting their expertise. The sad things is this is when the going gets the toughest, after a disater when the media and experts have pulled out.

Anyways NZ rocks!

Simpler Times Lake Taupo Bungi Jumping

Is There A Dr. In The House?

NO there is not. See Doc is playing in the sunshine in California. Long Beach, CA that is. I drove up from Oceanside about 80 miles south to see the bugger. You know he is all sunburned and man his wife must not feed him.  A good wind could take him away.  Just being a pain Doc.  He is well and it was great to see him. This is his nutty friend with Alzheimer's, just letting you know that today he is fine.

God Bless & Keep You &This Country of Ours!!!!
joe
Living With Alzheimers

BOOK SIGNING IN LONG BEACH: ALZHEIMER'S DISCUSSION and Q&A

I will be in Long Beach, California on Tuesday April 5th for two separate Alzheimer's Discussions and Book Signings for When Can I Go Home? I am pleased to say that the signings will be held at Two Neighborhood Branch Libraries of the very fine and extensive Long Beach Public Library System. 

First is Alamitos Neighborhood Library April 5th from 12-1 PM.

Later that Day at Los Altos Neighborhood Library April 5th from 4-5 PM.

Both Events are Free and open to the Public.

Don't Forget April 10-16 is National Library Week



My mother died of Alzheimer's disease.......

Wow, it has been two months since I posted on this blog. Not much new in the Alzheimer's world as far as cures or new effective treatments. Of course the National Alzheimer's project passed, if you are suffering with AD or are a caregiver, this really does not change much in your life on a day to day basis. Perhaps our children or our children's children will not have to be stricken with AD.

24 years ago today, March 6, 1987, my mother died from Alzheimer's disease. Her children were at her bedside as she took her last breath. It was five days before her seventieth birthday. I was 25 years old and a third year medical student. She had been diagnosed 9 years before she died and went through all the classic stages of AD. By the time she died it had been so long, since I had known her as my mother, since she was able to converse, laugh, smile, at times it was hard to remember her that way.

About 10 minutes before she died, I was sitting at the foot of her bed. (We were all holding vigil, she was fairly comatose, No feeding tube, just nasal cannula oxygen. She had been like that for almost two weeks/ We all wanted her to stop suffering, we wanted it to be over. For her torment and suffering at the hands of this rotten nefarious neurologically deteriorating process.)  In the final ten minutes of her physical life on earth, a wave of anguish came over me. I had a sense, some atavistic instinct that it was over.  She was leaving the earth.  I started to cry hard, and I felt so terrible, it seemed that all the years I had tried to be strong during her ordeal were coming out. I didn't want her to die, I wanted her to be back and be her old self. I knew somehow that it was over, the Alzheimer's had taken everything and the last thing left to take was her physical life, her breath.

The sad thing is, when you loose a parent to Alzheimer's, you feel like a part of yourself dies with them. That feeling never goes away. I think because it in part a living death every day. A slow progressive heartbreaking daily thing. On one hand you hope for a cure, and on another hand you want them to get better and die and stop suffering. It is a profoundly ambivalent form of grief. Then when they do physically die you are so damn heartbroken over the whole long drawn out process.
another year has clicked by. most of us always remember the date our parents died. I guess it is one more way to mark the life cycle.

To all those struggling, if you are having a bad day, hang in there, life is not static it is dynamic, it will not always feel as bad as today. If you are a caregiver and you loved one is having a good day, cherish it, laugh, smile, hold it in your heart forever. God Bless

Holding Hands

Sometimes, photos speak for themselves. My daughter holding hands with my dad yesterday at his assisted living home:

Inside the Mind of the Shooter, Mental Illness, Murder,

Well it is over a week since the Tuscon tragedy. I like you have watched all the events of the week unfold. The political manuevering over the week; the age old discussions and debates on mental illness are predicatable. I know this is an Alzhiemer's blog. My mother died from Alzheimer's disease 24 years ago. I took care of her, I wrote a book about it. I became a psychiatrist. I treat mental illness.
Lots of people want to know if Alzheimers is a mental illness. They want to know becouse there is much stigma associated with mental illness. People want to know what delusions are: so they come to this blog.
I get frustrated with  the lack of information on mental health and insanity and dangerousness that has been presented in the media this past week following the Arizona tragedy.
I have treated tens of thousands of patients with mental illness over the last 19 years.for various reaons  people dislike psychiatrists and are dissuaded from even begining to understand the plight of the mentlly ill in society.  People are afraid of those with metal illness. There is just so much stigma associated with it.
I have certainly bloggged about this phenomenon before. The stigma is even perpetuated by the propriatary, dismissive attitude toward mental health treatment by the medical community.
There are many initiatives by the goverment and insurance companies and administrative physicians and psychologist types (those that set policies, go to meetings, are 'indsipensible' and DON'T take care of patients all day) to basically "pigeon-hole" everything ie. all mental illness into "DEPRESSION".
It is leading to problems yet it is so politically correct becouse it looks like we are doing so much to improve mental health care delivery. It leads to problems, misdiagnosis, and improper treatment.

I believe we will hear more about this is in about a decade or so when the medical community at large and the policy-makers figure it out and  start to notice that not everything fits easily into the generic catagory of depression.  But you heard it here first. I often see patients that have been so mismanaged by a primary physician, it makes my job much more difficult. Yes it is true the easy cases that have been managed well by primary care, never have any need to come and see me, the specialist. Yet through no fault of their own we are also putting more pressure than ever on primary care do diagnose and treat mental illness.
I am pretty politically incorrect in saying this because sometimes political supercedes clincal, and most people in adminstrative roles don't like to listen to my clincal concerns, or they 'know better'. At any rate I keep doing my best in properly diagnosising and treating patient and taking care of people., in my speicalty.

Now as far as these insanity and murder issues. Insanity is a legal term. It does not mean much from a clinical perspective.   Mental competancy, capacity etc- all legal terms. Manipulated by attorneys, used and misused to sway juries one way or another.  Interpreted and misnterpreted by judges, lawyers and human beings serving on a jury. Human beings are emotional  and feeling people, and every "good" lawyer knows that. There is really no such things as objective facts that are not processed by a human being with emotions, but that is courtroom stuff, see lawyer blogs for that.
Clincally speaking here are the relevent details,
A good psychiatrist in evaluating a patient and arriving at a differential diagnosis  first must figure out if a person is psychotic or not. Psychotic means out of the realm of reality or "reality testing".  Psychotic is not hard to decipher for any reasonable, astute clinician. It manifests with some certain specific basic types of signs and symptoms, some basic signs are hallucinaitons and delusions. 
Hearing voices is a basic type of psychotic symptom, Once again for an astute clinician this is pretty basic and not difficult to diagnose.
I suppose the term astute is relative. I have evaluated and treated tens of thousands of patients in psychiatry, including lots of murderers, rapists and various other criminals.  So maybe I think it should not be too hard. The scary truth of the matter is, that many mental health practicioners  don't know there butt from a hole in the ground when it comes to evaluating if someone is psychotic or not. Many family doctors perhaps even a majority, are also not competent in evaluating if somone is psychotic or not.
So with that said becouse I have many years of experience in doing this, it makes some people angry resentful and hostile. "How can you tell if somone is psychotic from talking to them for a few minutes" I can't say much to that except, you don't call a plummer when there is a leak under your car, you call a mechanic. Part of the reason it makes poeple resentful that I have expertise in this area, is those people tend to have a horrible prejudice about mental illness. They consider diagosing somone with mental illness as some sort of value judgement. Perhaps a judgement on character, and since I am diangostician, I am the "judger" in their mind. It is more about the stigma and bias and fear those individuals carry about mental illness. As you might imagine it does nto motivate people to go into or stay in psychiatry.

Anyways here is a BASIC concept with tremendous relevence to the current geopolitical climate in the United States.. When it come to delusions (fixed beliefs not grounded in reality testing). There are certain basic areas to always ask about. for example Pre-occupations with Religious, somatic, and grandiosity and paranoia.
There are certain areas of paranoia to always inquire about when performing a psychiatric assessment.
These certian sub-areas of content in paranoia for example include such things as aliens, mind control, satanic, religious and government.   
This is something I learned all about over 20 years ago in my psychiatric training, It is something assessed in any competent psychiatric evaluation. It is something I have dealt with in patients and continue to deal with on a daily basis almost every day of my profesisonal life.
The concept of  paranoia about the government has always been a common theme in psychotic paranoia. not everyone with psychosis has this issue, but it is still common enough to always need to be assessed. It has absolutely nothing to do with the tea party, or Obama, or Bush, or Clinton, or Republicans or Democrats or Palin, or Beck, or Medow or Fox or CNBC. It has absolutely nothing to do with economic cycles.
The specific delusion may vary slightly with popular culture for example in the 1960's there may have been more psychotic people worried about martians or aliens from Mars when that science fiction was popular, in the 1980's there may have been more paranoid people worried about communists and Soviets doing bad things like planting microchips in ones brain while they slept. The point is psychotic paranoia is an illness and a common area of content involves goverment, mind ocntrol etc. Not new, not interesting per say, just a common area of psychitry, like a plumber fixing a leak, a computer tech fixing a slow hard drive.
Now when we talk of schizophrenia- a psyhcoitc disorder, that affects about 2% of the population WORLD-WIDE. That number is fairly consistent across cultures. In the USA that is 6 million people give or take a few.  Did Glenn Beck or OBama increase the number of schizophremic people in the United States? Absolutely not. It does not work that way.
Most people with schizophrenia are not dangerous or viloent. untreated paranoid schizophrenia can lead to more dangerousness. Wow!  How can a person like the Tuscon shooter slip through the cracks?
If this person who killed those innnoecnt people and wounded others, had had a psychiatrist, most likely that psychitrist would have been blamed. Thats how we view things in the USA. But he apparently did not have treatment, so we blame the inadequate system.

It is flawed and inadequate, not question there.

The fact of the matter is, if you take that 6 million people, many are not treated, no one knows exactly how many, but say a million. Those untreated individuals are out and about living with parents or homeless, or in college dorms or sitting around with a bunch or dis-enfranchised 20 year olds smoking pot doing whatever,being paranoid, threatening, fantasizing, obsessing about conspiracy, goverment control, mind control, or whatever delusional material you want. they cause disturbance sometimes, post things on facebook and internet, and usually fly under the radar and don't act on their threats or fantasies. It happens all the time eveyr day and all over the country. No one can predict with consistent accuracy which one sending off signals and warning signs is going to act. There are a lot of people sending off warning signals as we speak, and sadly they are nto getting help or treatment. The only thing that predicts future behavior is past acts.It is not new to this political climate and has been happening for centuries.
Schizoprehnia starts when you are young. It is a chronic incurrable disease of young people typically with onset around 17-25 years of age.There is not a cure. It is treatable but not curable.
So what do we do?
The currect system is flawed. Yes lawyers and the ACLU and society in general wants to protect peoples civil rights. Yes the mental health system has committed abuses namely by neglect, in state hospital about 60-90 years ago. The pendulum has swung the other way. We have the media, angry reporters so mis-informed and condemming doctors, drug companies and the like. We have family doctors poorly trained in mental health and psychitatry or not trianed at all, trying to categorize and treat mental illness, and sometimes making it worse. We have very few young physicians going into psychiatry. In my community and in many communities we have untrained psychologists trying to pracitce psychopharmacology and advise family doctors how to practice psychiatry. The situaiton is unbelievable. We have psychologists and psychotherapists and the media and even certain members in the medical commiunity at  large cristicizing psychiatry, and of course that coupled with very low pay compared to every other medical speicalty except pediatrics- For all the young doctors coming out of medical school. almost NO ONE wants to train in and practice psychiatry.

So what was going on in the mind of the shooter? Did he have schizphrenia? Most likely from the bits and pieces presented by the media. Paranoia is a projection of one's aggressive drives. Every single person has drives: eg aggressive drives, sex drive, hunger drive,  but we are higher functioning psychological beings so we learn to surpress and repress and sublimate aggresive drives, we become social and empathic and compassionate beings hopefully. It takes some reaonsable genetics and environmental nurturing at an early age. 
A person with schizophrenia may hear voices, they may become so fixated on their delusional beliefs that can't think about anything else. It becomes all encompassing. They become paranoid: that is thinking others are out to hurt them or kill then because it is too psyhcologically overwhelming and forbidden and destructive to deal with aggressive drives.  The process is highly unconscious. Sort of like dreaming.
A Psychological projection is what paranoia is.  A primitive drive, a desire to hurt someone, projected onto somone else. "They want to hurt me"  nothing new, a psychological understanding that has been around for a hundred years, that many therapists in this day and age do not learn or have a concept of,
generally viewed as a bunch of psychobabble BS. Except if you understand the psychological defense it makes a lot of sense.
In this day and age there is much more biological theory on schizphrenia than psychological theory. Dopamine,  has been classically linked to schizophrenia, people with schizophrenia have structural changes in their brain that others do not, for example they have larger cerebral ventricles.
Twins raised apart in different environments from birth have a higher incidence of schizophrenia  between them. That is if one twin has schizophrenia, the liklihood of the other having it, despite different environments is higher than average probability- Leading to the theory that there is some genetic component to schizophrenia. Like Alzheimer's though, the exacct genetic links are not  well understood.v Other neurotransmitter like glutamte and glycine and many others have been and are being studied,
Another way of thinking about schizophrenia, is that the mind of a schiophrenic is  almost like someone without schizophrenia having a bizzare dream. There is no time relationship in dreams they are often weird and bizzare, and then you wake up.
Some data shows that people with schizophrenia when relaying the content of their dreams have very NORMAL dreams. that su what would be considered normal everyday life for somone that does not have schizophrenia. Dreaming is a psyhoclogical primary process. Another possible way to think about or understand schizophrenia is being  in a bizzare dream where you can't wake up.   Only that person with schizophrenia is wide awake and conscious.

Well I could talk about this stuff all day. I wish there was less stigma, I wish the media could do more accurate reporting. I wish there was not always a political platform somewhere. This is my job, it is what I do. I often deal with dangerous patients and sometimes my life is life is at risk.
Mental illness and the inadequacy of the system only seems to get addressed ion the collecitve consciousness of Americans over situations like Tuscon. I wish the dialogue would continue, I wish the politcs were taklen out. Inevitably however, the politics will continue and the mental health dialogue will slowly die out over the weeks.

Hello

Hi Doc,

Thought I stop by and wish all of your followers and your family, I am not sure about you though, a very happy new year.

For me it will get worse, last year things progressed, this year maybe I will forget all and have no resentments because I cannnt remember ther.

God Bless & Keep You,
joe

I took my dad's 57 Chevy down to the assisted living today. When he saw it he said (paraphrasing) "That looks like the one I used to have." I of course told him it was his. I asked him if he would like to go for a ride. He said "Hell yeah." We drove around for a short time, he did not say much but he absolutely loved it. Today was a good day. I am attaching a pic. Thanks be to God.